Criteria for Ending the Distal Fusion at the L3 Vertebra vs. L4 in Surgical Treatment of Adolescent Idiopathic Scoliosis Patients with Lenke Type 3C, 5C, and 6C Curves: Results After Ten Years of Follow-up.

Introduction The selection of the most distal caudal vertebra in spinal fusion surgeries in adolescent idiopathic scoliosis patients with structural lumbar curvatures is still a matter of debate. The aim of this study was to determine the preoperative radiological criteria on the traction X-rays under general anesthesia (TrUGA) for selection between the L3 and L4 vertebrae and to assess the efficacy of these criteria via the long-term results of patients with Lenke Type 3C, 5C, and 6C curves. Methods Radiological data of 93 patients (84 females, 9 males) who met the inclusion criteria were retrospectively evaluated. The relationship between the L3 vertebra and the central sacral vertebral line, the portion of the L3 vertebra in the stable zone of Harrington, the parallelism of the L3 with the sacrum, and the tilt and rotation of the L3 on TrUGA radiographs were evaluated for the selection of the lowest instrumented vertebrae (LIV). Clinical results were analyzed using the Scoliosis Research Society-22 (SRS-22) questionnaire. Results The mean follow-up period of the study group was 149.3 months. According to the Lenke classification, 29 patients had Type 3C, 33 had Type 5C, and 31 had Type 6C curves. The preoperative analysis was based on standing anteroposterior (AP), supine traction, and bending X-rays, and the L3 vertebra was selected as the LIV in 37 patients (40%). These X-rays suggested L4 as the LIV in 56 patients (60%); however, based on our study criteria, the L3 vertebra was selected. No significant loss of correction was observed nor additional surgery due to decompensation was required in the follow-up period. Conclusion  The use of TrUGA radiographs with the identified criteria is an efficient alternative method in the selection of the LIV in patients with Lenke Type 3C, 5C, and 6C curves.

Pott's Disease in a 2-Year-Old Child Treated by Decompression and Anterior-Posterior Instrumented Fusion.

Introduction. Paraplegia and kyphotic deformity are two major disease-related problems of spinal tuberculosis, especially in the early age disease. In this study a 2-year-old boy who underwent surgical decompression, correction, and 360° instrumented fusion via simultaneous anterior-posterior technique for Pott's disease was reported. Case Report. A 2-year-and-9-month-old boy presented with severe back pain and paraparesis of one-month duration. Thoracic magnetic resonance imaging demonstrated destruction with a large paraspinal abscess involving T5-T6-T7 levels, compressing the spinal cord. The paraspinal abscess drained and three-level corpectomy was performed at T5-6-7 with transthoracic approach. Anterior instrumentation and fusion was performed with structural 1 autogenous fibula and rib graft using screw-rod system. In prone position pedicle screws were inserted at T4 and T8 levels and rods were placed. Six months after surgery, there was no weakness or paraparesis and no correction loss at the end of follow-up period. Discussion. In cases of vertebral osteomyelitis with severe anterior column destruction in the very early child ages the use of anterior structural grafts and instrumentation in combination with posterior instrumentation is safe and effective in maintenance of the correction achieved and allows efficient stabilization and early mobilization.

Clinical and radiological morphometry of posterior parts of thoracic and lumbal vertebras.

The aim of this work is to measure clinically important dimensions of thoracic and lumbal vertebras. Charts of one-hundred and seventeen patients with implanted internal fixateur on the thoracic and lumbal spine between 01.01. 2008. and 31.3.2010. at the Department for Orthopedics and Traumatology, of the Sarajevo Clinical center were retrieved, and only 14 patients, with 46 vetrtebras and 89 pedicles have had complete documentation (clearly visible measured structures on X-ray and CT scans). Digitalized antero-posterior and latero-lateral X-ray, and transversal and sagital CT scans were basic inputs for measurement of height and width of the pedicle--PH, PW, axial and vertical cortico-cortical transpedicular distances--AL, VL, and interpedicular distance--IP. The correction of enlargement on X-ray pictures was performed according to known dimensions of implants and length scale on CT scans. Enlargement of those parameters, from T1 to L5 level was from 50 to 150%. This increasing was not always linear, sometimes there was even decreasing. For instance, the IP on second and third thoracic vertebra was shorter compared to the first thoracic vertebra. Pedicles from the third to the eighth thoracic vertebra were narrower compared to the second thoracic vertebra. The importance of this work is in to analyze the mentioned dimensions by methods available to the clinician. Every other in vivo measurement is impossible because of the excessive surgical approach, while preoperative CT scanning with a great number of slices per one millimeter for this purpose is not ethical.

The results of simultaneous posterior-anterior-posterior surgery in multilevel tuberculosis spondylitis associated with severe kyphosis.

We retrospectively studied the cases with tuberculous spondylitis of thoracolumbar region with two or more levels of involvement that underwent posterior instrumentation and fusion and anterior fusion with titanium mesh following anterior decompression using simultaneous successive posterior-anterior-posterior surgery. Among all patients with tuberculous spondylitis accompanied by medium or severe kyphosis, 20 patients who underwent simultaneous successive decompression, fusion and instrumentation with posterior-anterior-posterior surgery between 1999 and 2004 were included in the study. Patients were evaluated for fusion formation and neurological and functional status. Kyphosis angles were measured at early and long-term follow-up. Antituberculosis chemotherapy was initiated in all patients and continued for 9 months; initially as quadruple therapy for 3 months, and then as triple therapy. Average follow-up period was 52.7 months (range 37-94). Solid fusion was achieved in all patients. All patients returned to their previous occupation; 75% (15 subjects) with mild pain or no pain and 15% (3 subjects) with major limitations. There were 11 patients with neurological deficit, 9 of these achieved complete neurological recoveries. Regarding kyphosis angle, an average 35.1° correction (84.8%) was obtained in postoperative period (p < 0.001) and there was no significant correction loss during the follow-up period (p < 0.05). There were no grafts or instrumentation-related stabilization problems. In subjects with tuberculous spondylitis with involvements at two or more levels accompanied by medium and severe kyphosis, decompression, fusion and instrumentation by simultaneous successive posterior-anterior-posterior surgery is an effective and safe management method for effective kyphosis correction with high fusion rates.

Giant sacral schwannoma: a case report and review of the literature.

Intraspinal schwannomas localized in the sacrum are relatively infrequent, accounting for 1-5% of all spinal axis schwannomas. They frequently grow to considerable size before detection; hence, the term giant sacral schwannoma. Sacral schwannomas arise from the sacral nerve roots. The diagnosis of schwannomas in the spinal canal is difficult because of their slow growth, often resulting in extensive bony destruction. This case report documents the management of a 48-year-old male with a giant sacral schwannoma. We performed a two-stage surgery with intralesional tumour resection. The patient is now free of any complaint, complications and there is no recurrence two years after resection of the schwannoma. Intralesional excision of a sacral schwannoma is a less invasive procedure than total or partial sacrectomy. Using a combined anterior and posterior approach, satisfactory tumour excision and stabilization can be achieved, while avoiding the high morbidity related with total sacrectomy.

The pedicle screw fixation with vertebroplasty augmentation in the surgical treatment of the severe osteoporotic spines.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To present the early clinical results of pedicle screw fixation augmented by vertebroplasty using polymethylmethacrylate in severely osteoporotic patients requiring spine surgery due to the neurologic deficit. SUMMARY OF BACKGROUND DATA: It is postulated that combining a formal vertebroplasty-that is, maximum filling of the trabecular space with polymethylmethacrylate-with pedicle screw placement in osteoporotic vertebrae could result in resistance to pullout forces significantly. METHODS: Between the years 2003 and 2006, pedicle screw placement with vertebroplasty augmentation was performed in 49 patients who had severe osteoporosis and who required spine surgery due to neurologic deficit. Eleven patients with less than 2 years of follow-up and 2 patients who died from unrelated illness were excluded from the study. Thirty-six of 49 patients having minimum 2 years of follow-up were included. Cement augmentation was also performed in segments proximal and distal to instrumentation to prevent junctional segment fractures. Early and late postoperative complications were recorded during follow-up. RESULTS: The mean postoperative follow-up was 37 (24 to 48) months. The average age of the patients was 66 (59 to 78) years. The instrumentation was performed meanly at 5 segments and vertebroplasty was performed averagely at 7 segments. All patients had the T-score value of less than -2.5 from the anteroposterior and lateral lumbar spine and hip views, so regarded as severe osteoporosis. In our study group, there were no extravasation and subsequent thermal neural injury. Four superficial wound infections have been observed and they responded well to local debridement and antibiotics. There were no proximal and distal junctional segment fractures during the follow-up course. Postoperatively, all patients with neurologic symptoms had complete relief of their nerve compression symptoms. CONCLUSIONS: In patients requiring spine surgery due to neurologic deficit and having no sufficient time for the medical treatment of severe osteoporosis, pedicle screw fixation with vertebroplasty augmentation and vertebroplasty in segments proximal and distal to the instrumented segments can be good alternative methods to provide well fixation and fusion while preventing proximal and distal junctional fractures. One should be careful about pulmonary cement embolism after such kind of procedures.

A rare cause of neuromuscular scoliosis: Alexander disease.

Alexander disease belongs to a group of progressive neurological disorders in which the destruction of white matter in the brain is accompanied by the formation of fibrous, eosinophilic deposits known as Rosenthal fibers. Spinal deformity rarely accompanies this disease. The aim of this report is to present a patient with juvenile-onset Alexander disease, who also had progressive neuromuscular type scoliosis requiring surgical stabilization. A 13-year-old male presented with bilateral weakness in both lower extremities and scoliosis. Results of an examination of the spine showed a left thoracic scoliosis with prominent left paraspinous prominence and elevation of the ipsilateral shoulder. Spinal fusion with rigid internal stabilizing instrumentation was selected for surgical treatment of the scoliosis. The fusion area was to be from T2 to L4. He was instrumented with pedicle screw fixation system, and he underwent fusion with an allogenous bone graft. Satisfactory correction of the sagittal and coronal plane deformity was achieved, reducing the scoliosis to 14 degrees . At the 5-year follow-up, results of a clinical examination showed a marked improvement in truncal balance and walking ability. The patient had a rapidly progressive scoliosis and severe decompensation requiring surgical stabilization. The scoliosis behaved in a manner similar to that of neuromuscular scoliosis. Therefore, more aggressive treatment was warranted to prevent decompensation. For that reason, posterior long segment (T2-L4) pedicle screw instrumentation and fusion was performed for surgical treatment.

Double-segment total vertebrectomy for the surgical treatment of congenital kyphoscoliosis: a case report.

BACKGROUND CONTEXT: Congenital kyphosis or kyphoscoliosis is an uncommon deformity that usually is progressive without surgical intervention. In the lately diagnosed or neglected cases of congenital kyphoscoliosis, the patients may come with shoulder-trunk imbalance anomalies, severe deformity in coronal and sagittal plane, rib cage deformities, pelvic tilt, presence of intramedullary anomalies, neurological deficit, and difficulty in walking and cardiopulmonary problems. PURPOSE: To present a technical note related with double-segment total vertebrectomy for the surgical treatment of a patient who had neglected congenital kyphoscoliosis in lumbar spine. STUDY DESIGN: Case report. METHODS: A 19-year-old girl had submitted to our center with complaints of deformity and pain in her back. Her physical examination revealed scoliosis and gibbosity in lumbar region. Her neurological examination was normal. In the radiological examination, X-ray films showed 42 degrees lumbar scoliosis in frontal plane and 35 degrees kyphotic curvature in the sagittal plane. RESULTS: Three-staged (posterior-anterior-posterior) surgery in the same session (same anesthesia) was performed. CONCLUSION: Total or partial vertebrectomy on the apex of the deformity and the adjacent vertebral bodies along with anterior stabilization by means of a cylindrical cage combined in one operative procedure preceded by temporary posterior instrumentation and followed by posterior instrumentation and fusion may be preferred for the treatment of congenital kyphoscoliosis in neglected cases to provide spinal cord decompression.

Posterior only pedicle screw instrumentation with intraoperative halo-femoral traction in the surgical treatment of severe scoliosis (>100 degrees).

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To report the results of surgical correction achieved by intraoperative halo-femoral traction and posterior only pedicle screw instrumentation in severe scoliosis (scoliosis greater than 100 degrees ). SUMMARY OF BACKGROUND DATA: Although previous reports show the effectiveness of preoperative halo traction in the treatment of severe spinal deformity, the intraoperative use of halo-femoral traction in conjunction with posterior pedicle screw instrumentation has never been reported in patients with severe spinal deformity. METHODS: A total of 15 consecutive patients with severe (>100 degrees) thoracic idiopathic scoliosis and/or kyphoscoliosis operated by using intraoperative halo-femoral traction and posterior only pedicle screw instrumentation were included in the study. Subjects were analyzed by age at date of examination, gender, major coronal curve magnitude, major compensatory coronal curve magnitude, major sagittal curve magnitude, shoulder imbalance, and preoperative vital capacity of the lungs. Halo-traction related complications and short- and long-term complications were noted in each case. RESULTS: The average age at the time of surgery was 17.8 years (range, 16-19). There were 4 males and 11 females. The average improvement was 51% in the major thoracic curve, 33% in the compensatory lumbar curve, and 53% in the major sagittal curve. The average follow-up was 56 (range, 24-96) months. Loss of correction averaged 4 degrees for major thoracic curves and 2 degrees for thoracic kyphosis based on measurements at the final follow-up date. CONCLUSION: The use of intraoperative halo-femoral traction together with the wide facet resection and posterior release gradually provide a good correction and balance maintained by pedicle screw instrumentation. Intraoperative halo-femoral traction not only elongates spinal column but also elongates the thoracic cavity improving the compromised pulmonary function.

Degenerative lumbar spinal stenosis: correlation with Oswestry Disability Index and MR imaging.

Because neither the degree of constriction of the spinal canal considered to be symptomatic for lumbar spinal stenosis nor the relationship between the clinical appearance and the degree of a radiologically verified constriction is clear, a correlation of patient's disability level and radiographic constriction of the lumbar spinal canal is of interest. The aim of this study was to establish a relationship between the degree of radiologically established anatomical stenosis and the severity of self-assessed Oswestry Disability Index in patients undergoing surgery for degenerative lumbar spinal stenosis. Sixty-three consecutive patients with degenerative lumbar spinal stenosis who were scheduled for elective surgery were enrolled in the study. All patients underwent preoperative magnetic resonance imaging and completed a self-assessment Oswestry Disability Index questionnaire. Quantitative image evaluation for lumbar spinal stenosis included the dural sac cross-sectional area, and qualitative evaluation of the lateral recess and foraminal stenosis were also performed. Every patient subsequently answered the national translation of the Oswestry Disability Index questionnaire and the percentage disability was calculated. Statistical analysis of the data was performed to seek a relationship between radiological stenosis and percentage disability recorded by the Oswestry Disability Index. Upon radiological assessment, 27 of the 63 patients evaluated had severe and 33 patients had moderate central dural sac stenosis; 11 had grade 3 and 27 had grade 2 nerve root compromise in the lateral recess; 22 had grade 3 and 37 had grade 2 foraminal stenosis. On the basis of the percentage disability score, of the 63 patients, 10 patients demonstrated mild disability, 13 patients moderate disability, 25 patients severe disability, 12 patients were crippled and three patients were bedridden. Radiologically, eight patients with severe central stenosis and nine patients with moderate lateral stenosis demonstrated only minimal disability on percentage Oswestry Disability Index scores. Statistical evaluation of central and lateral radiological stenosis versus Oswestry Disability Index percentage scores showed no significant correlation. In conclusion, lumbar spinal stenosis remains a clinico-radiological syndrome, and both the clinical picture and the magnetic resonance imaging findings are important when evaluating and discussing surgery with patients having this diagnosis. MR imaging has to be used to determine the levels to be decompressed.

Severe erosion of lumbar vertebral body because of a chronic ruptured abdominal aortic aneurysm.

BACKGROUND CONTEXT: Erosion of vertebral bodies because of abdominal aortic aneurysm is an extremely rare condition. This vertebral destruction is usually seen after aortic graft surgery; nevertheless, it is not expected in primary aortic aneurysms. PURPOSE: The purpose of this article was to present a patient who suffers from back and hip pain because of a chronic ruptured primary aortic aneurysm. STUDY DESIGN: Case report. METHOD: A 51-year-old patient had complaints of back pain. Physical examination revealed a pulsatile mass in the periumblical region. By using conventional radiographies, vertebral erosion was detected at the anterior part of L3-L4-L5 vertebrae. A chronic ruptured thrombosed aortic aneurysm was identified by magnetic resonance imaging. RESULTS: After resection of the aneurysm, it was possible that the lack of anterior column support could result in future instability. Therefore, an L4-L5 anterior partial corpectomy and reconstruction of the anterior defect with titanium mesh cage with posterior instrumentation and fusion were performed. CONCLUSION: It was concluded that back pain caused by chronic aortic aneurysms is a rare condition and may be one of the possible etiologies in differential diagnosis of low back pain and/or sciatica in some patients.

Posterior vertebrectomy in kyphosis, scoliosis and kyphoscoliosis due to hemivertebra.

Vertebrectomy and instrumentation only via the posterior approach has been increasingly used in sagittal, frontal plane and combined deformities. The aim of this retrospective study is to evaluate the clinical and radiological results of hemivertebrectomy and instrumentation only via the posterior approach in congenital spinal deformities. Between 1998 and 2003, we performed hemivertebrectomy and interbody fusion using posterior instrumentation with titanium mesh cage via the posterior approach in 19 patients (three scoliosis, five kyphosis and 11 kyphoscoliosis). The age of the patients ranged from 2 to 22 years and they all underwent hemivertebrectomy (at thoracic level in six patients, at thoracolumbar level in eight patients and at lumbar level in five patients). A titanium mesh cage was used for anterior column support and interbody fusion in patients who had residual anterior gap preventing bone-to-bone contact. Correction and stabilization were achieved by posterior polyaxial pedicle screws. Follow-up was an average of 4.6 years (range: 2-7 years). We did not confront any loss of correction, pseudoarthrosis, and titanium mesh cage collapse or implant failure. Hemivertebrectomy and instrumentation via the posterior approach is a good one-stage surgical treatment option that can be used to avoid the surgical trauma and morbidity related to anterior surgery. It is a technically demanding surgical procedure, however, requiring extreme care and experience in spine surgery.

Comparative analysis of pedicle screw versus hybrid instrumentation in adolescent idiopathic scoliosis surgery.

The expectations of both the patient and surgeon have been greatly revised in the last 10 years with the introduction of pedicle screws (PS) in spinal surgery. In this study, we have retrospectively evaluated and compared the results of PS instrumentation and the Hybrid System (HS), the latter consists of pedicle screws, sublaminar wire and hooks. The mean follow-up period was 60.1 months (range: 49-94 months) for the patients of the HS group and 29.3 months (range: 24-35 months) for those of the PS group. In the HS group, pedicle screws were used at the thoracolumbar junction and lumbar vertebra, the bilateral pediculotransverse claw hook configuration was used at the cranial end of the instrumentation, sublaminar wire was used on the concave side of the apical region and the compressive hook was used on the convex side. In the PS group, PS were used on the concave sides at all levels and on the convex side of the cranial and caudal end of instrumentation, in the transition zone and at the apex. The two groups were comparable for variables such as mean age, preoperative Cobb angle, thoracic kyphosis angle, lordosis angle, coronal balance, flexibility of the curve, apical vertebra rotation (AVR), apical vertebra rotation (AVT) and the number of vertebrae included in the fusion (p>0.05). The parameters of values of correction, ratio of correction loss, AV derotation, AVT correction ratio, amount of blood loss, operation time, postoperative global coronal and sagittal balance, thoracic kyphosis angle and lumbar lordosis angle were measured at the last follow-up and used for comparing the HS and PS groups. There was no statistically significant difference between the groups for correction ratio, postoperative coronal balance, postoperative thoracic kyphosis and lumbar lordosis angle, operation time, amount of blood loss and number of fixation points (p>0.05) The difference for the ratio of correction loss, AV derotation angle and the AVT correction ratio at the last follow-up visit and for the total follow-up period between the groups was found to be statistically significant (p<0.05). Although it is possible to obtain a similar amount of correction by either instrumentation system, the loss of correction seems to be lower with the more rigid PS construction. The PS system also has a stronger effect on vertebral bodies, thereby providing better AV de-rotation. There was no significant difference (p>0.05) between the groups in terms of correction rate, postoperative coronal and sagittal balance, operation time, blood loss and number of fixation points. This may indicate that anchor points are more important than the use--or not--of screws. Correction durability and AV de-rotation was better with PS instrumentation, while AVT was better corrected by HS instrumentation (p<0.05). We propose that the reason for the better correction of AVT with HS instrumentation is the forceful translation offered by the sublaminar wire at the apical region, while the reason for the better correction durability of the PS instrumentation may be due to the fact that multiple pedicle screws which afford three-column control are better at maintaining the correction and preventing late deterioration.

A 13-year-old textiloma (gossypiboma) after discectomy for lumbar disc herniation: a case report and review of the literature.

BACKGROUND CONTEXT: A paraspinal retained surgical sponge (textiloma) is rare and mostly asymptomatic in chronic cases but can be confused with other soft-tissue masses. Therefore, it is important to be aware of patients with a paraspinal soft-tissue mass with unusual or atypical symptoms. PURPOSE: A patient with asymptomatic chronic paraspinal textiloma who was operated on 13 years ago for lumbar disc herniation is presented. STUDY DESIGN: Case report. METHODS: A patient presented with complaints of back pain radiating to leg and neurogenic claudication. Computed tomography imaging revealed canal stenosis at L3-L5 levels and a soft-tissue mass at the paraspinal muscles of the L5-S1 level. RESULTS: Surgical treatment was performed for both to excise or obtain biopsy from the soft-tissue mass and to treat spinal stenosis. During the operation, a retained surgical sponge was found and excised completely with fibrous capsule surrounding it and decompression and posterior spinal instrumentation performed without fusion for spinal stenosis with dynamic pedicle screws (Cosmic Pedicle Screw System; Ulrich AG, Germany). Recovery was uneventful, and the patient's stenosis symptoms were resolved soon after surgery. CONCLUSION: Retained surgical sponges do not show mostly any specific clinical and radiological signs. They should be included in differential diagnoses of soft-tissue masses at the paraspinal region with a history of a previous spinal operation.

Treatment approach in tandem (concurrent) cervical and lumbar spinal stenosis.

Spondylotic degeneration can manifest as tandem (concurrent) cervical and lumbar spinal stenosis. The primary manifestations include neurogenic claudication, gait disturbance and a mixture of findings of myelopathy and polyradiculopathy in both the upper and lower extremities. The purpose of this retrospective study was to report the existence and management of tandem (concurrent) cervical and lumbar spinal stenosis. Between 1998 and 2004, 8 patients (6 women and 2 men) were diagnosed with tandem spinal stenosis in a series of 230 patients who underwent surgery for spinal stenosis (3.4%). Three patients received cervical surgery first and 5 patients lumbar surgery first. The Japanese Orthopaedic Association Score of all patients improved from an average of 8.1 preoperatively to an average of 11.8 points at discharge and maintained an average of 12.7 points at final follow-up. Oswestry Disability Score improved from mean 58.1 to 29 at discharge and 19.3 at latest follow-up. All the patients had excellent or good results and none deteriorated neurologically. Although tandem spinal stenosis occurred relatively infrequently, we concluded that its possible presence should not be overlooked. The treatment plan must be designed according to the chief complaints and symptoms of the patient.

Solitary osteochondroma of the cervical spine causing spinal cord compression.

Osteochondromas are common benign tumours of bone that often occur in the metaphysodiaphyseal parts of long bones. They rarely occur in the spine. We present a case of solitary osteochondroma arising from the C-1 vertebral lamina, causing neurological symptoms. A 46-year-old man presented to our institution, complaining of pain and numbness originating from his neck and extending down to his left arm. Radiographs, CT and MRI showed a solitary benign appearing expansile bone tumour arising from the left vertebral lamina of C-1, spreading to C-2, exerting an eccentric posterolateral compression on the spinal cord in the left part of the spinal canal and causing stenosis of the left neural foramen between C-1 and C-2. The lesion was surgically explored through a posterior longitudinal incision. Leaving the left lateral mass of C-1 intact, a left hemilaminectomy was performed. The lesion and the part spreading to C-2 were excised, completely clearing the spinal cord compression. For posterior stabilisation, lateral mass screws were inserted bilaterally in C-1 and pedicle screws and a rod system were used in C-2. The interlaminar region between C-1 and C-2 was fused using cancellous allograft chips. Follow-up controls with radiological examination revealed that the decompression had been adequate and fusion was achieved. Excision of the lesions is necessary to relieve neurological compression in such cases. In order to avoid complications associated with instability following extensive laminectomy, posterior stabilisation and fusion should also be performed.

Simultaneous surgical treatment in congenital scoliosis and/or kyphosis associated with intraspinal abnormalities.

STUDY DESIGN: Retrospective clinical study. OBJECTIVE: To show retrospective analysis of 21 consecutive patients who underwent simultaneous surgical treatment for progressive spinal deformity and coexisting intraspinal pathologies (tethered cord and/or diastematomyelia). SUMMARY OF BACKGROUND DATA: The classic advocated approach in patients with congenital spine deformity associated with intraspinal anomalies is first to perform surgery for the intraspinal pathologies and then surgery for correction and stabilization of the deformity 3 to 6 months later. To our knowledge, there is no study on simultaneous surgical treatment for these 2 associated conditions. METHODS: In the surgery; after the exposure of the determined levels, placement of all pedicle screws was performed as the initial part of surgical procedure. Then surgical treatment for intraspinal pathology was performed by the neurosurgical team and then followed by completion of instrumentation and correction of the deformity. Additional anterior surgery was done later to prevent pseudarthrosis and crankshaft phenomenon. RESULTS: The mean age of the patients at presentation ranged from 3 to 19 years (mean, 13 years). There were 17 female patients and 4 male patients. Four patients had neurologic deficits at the time of presentation, and all 4 had associated kyphosis. The mean operation time was 9.3 hours (range, 7-12 hours) and the mean blood loss was 1980 mL (range, 1500-3000 mL). The average follow-up was 6.8 years (2-12 years). None of the patients experienced deterioration in their neurologic status after surgery. None of the patients had infection, pseudarthrosis, or loss of correction during the follow-up visits. CONCLUSION: The simultaneous surgical treatment for congenital deformity and intraspinal abnormality does not involve significant complications and seems to be an alternative and safe treatment option.

[Total disc prosthesis for painful degenerative lumbar disc disease]. / Lomber dejeneratif disk hastaligii total disk protezi ile tedavisi.

OBJECTIVES: We evaluated clinical and radiographic results of patients treated by the ProDisc II total disc prosthesis (TDP) for painful degenerative lumbar disc disease. METHODS: The study included 34 patients (25 females, 9 males; mean age 44 years; range 37 to 54 years) who underwent a total of 62 lumbar TDP procedures for degenerative lumbar disc disease. Lumbar disc replacement involved one level in 12 cases, two levels in 17 cases, three levels in four cases, and four levels in one case. Clinical and radiographic assessments were made preoperatively and at 3, 6, 12, and 24 months postoperatively. Clinical evaluations were made with a visual analog scale (VAS) and the Oswestry Disability Index (ODI). Radiographic parameters included lumbar lordotic angle, the height and flexion-extension range of the affected discs. The mean follow-up period was 29.3 months (range 24 to 39 months). RESULTS: Low back pain and lower extremity pain showed near-complete improvement up to the third postoperative month. At the end of the 24th month, preoperative ODI and VAS scores of 59.6 and 7.8 decreased to 19.8 and 1.0, respectively. Preoperative and postoperative lumbar lordotic angles were 52.6 degrees and 57.1 degrees , respectively. The mean disc height of implanted discs increased from 4.6 mm to 12.1 mm postoperatively. The mean flexion-extension angle increased from 2.8 degrees to 8.4 degrees at L5-S1, and from 2.6 degrees to 9.8 degrees at L4-5. The overall improvement in the mean flexion-extension angle was 7.2 degrees . CONCLUSION: Lumbar disc prosthesis offers significant advantages in terms of functional improvement and increased quality of life in the surgical treatment of degenerative disc disease.

Bilateral L5 radiculopathy due to osteoporotic L1 vertebral fracture: A case report.

BACKGROUND: The true incidence of osteoporotic vertebral fractures is not well defined because many osteoporotic vertebral fractures are asymptomatic. Although the true incidence of neurological compromise as a result of osteoporotic vertebral fractures is not known, it is thought to be low. In this case report, we present a case of L1 osteoporotic vertebral fracture causing bilateral L5 nerve root compression and manifestation of bilateral foot-drop. METHODS: Pedicle screws were inserted in the vertebrae, 2 above and 2 below the L1 vertebra. A temporary rod was placed on the left. An L1 right hemilaminectomy via a posterior approach and a corpectomy were performed. The spinal cord was decompressed. Anterior fusion was carried out by placing titanium mesh cage into the vertebrectomy site as a strut graft via posterior approach, and posterolateral fusion with spongious allografts were added to the procedure. RESULTS: Two years later the patient was completely symptom free and receiving medical treatment for osteoporosis, which was diagnosed as primary type. CONCLUSION: If a fracture is detected on the posterior wall of the vertebral body in computerized tomography (CT) examination with plain radiographs, a magnetic resonance imaging (MRI) examination should be conducted in the presence of symptoms and physical findings suggestive of neurological compression. Follow-up neurological examinations should be carried out, and it should be kept in mind that most of the neurological symptoms may develop late and manifest as radiculopathy. The majority of the osteoporotic vertebral fractures can be managed conservatively with bed rest and orthosis, but cases with accompanying neurological deficit should be managed surgically using decompression and stabilization by fusion and instrumentation.

Symptomatic polyostotic fibrous dysplasia of the thoracic spine.

We present a case of polyostotic fibrous dysplasia with limited involvement in thoracic spine and adjacent ribs. The patient underwent posterior instrumentation performed between Th3 and Th11 with pedicle screw system, followed by costotransversectomy of 7th and 8th costovertebral junctions and posterior spinal fusion for costal lesions. In the same operation, curettage was done for the lesion in Th6 vertebra and bone grafting and anterior total corpectomy were performed for Th7 and Th8 vertebrae. 360 degrees spinal fusion was done using titanium mesh as strut graft and autogenous rib grafts. Fibrous dysplasia occurs rarely in axial bones than peripheral bones. The cystic lesions in segments of the whole spine should be evaluated for the possibility of fibrous dysplasia with detailed radiographical examination and biopsy.